Gary Whitlock

Diagnostics within the clinic to test for gonorrhoea and chlamydia reduces the time to treatment: a service evaluation

Rapid on-site diagnostics permit prompt recognition and treatment of infections. We introduced the GeneXpert system (Cepheid, California, USA) within 56 Dean Street, a central London sexual health clinic. The machine processes Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) samples in 90 min by real-time PCR. We present the results of the service evaluation of a pilot where GeneXpert was used to process samples from individuals attending outreach or specialised clinics. Asymptomatic attenders whose samples were processed using the GeneXpert system were compared with asymptomatic ‘standard of care’ …

Not just PrEP: other reasons for London's HIV decline

www.thelancet.com/hiv Vol 4 April 2017 e153 Diagnoses started to fall in the autumn of 2015 (figure). In 2014, we opened Dean Street Express, reducing time to treatment for chlamydia and gonorrhoea from 10 days to 2 days. Given that both these infections are drivers of HIV transmission, their early treatment may have played a part in the decline in new infections. Additionally, the opening of Dean Street Express was linked to a significant increase in HIV testing in high risk men who have sex with men (MSM). Other factors likely to have had an effect are that we prescribe over a quarter of the HIV post-exposure prophylaxis in the UK (2637 of 9609 prescriptions in 2015), and the Dean Street Wellbeing Programme promoting regular testing in high risk MSM, including those practising chemsex. Not just PrEP: other reasons for London’s HIV decline

High HIV incidence in men who have sex with men following an early syphilis diagnosis: is there room for pre-exposure prophylaxis as a prevention strategy?

Objectives HIV pre-exposure prophylaxis (PrEP) is becoming a pivotal strategy for HIV prevention. Understanding the impact of risk factors for HIV transmission to identify those at highest risk would favour the implementation of PrEP, currently limited by costs. In this service evaluation, we estimated the incidence of bacterial STIs in men who have sex with men (MSM) diagnosed with early syphilis attending a London sexual health clinic according to their HIV status. In addition, we estimated the incidence of HIV infection in HIV-negative MSM, following a diagnosis of early syphilis. Methods We undertook a retrospective case note review of all MSM patients diagnosed with early syphilis between January and June 2014. A number of sexual health screens and diagnoses of chlamydia, gonorrhoea and HIV were prospectively analysed following the syphilis diagnosis. Results 206 MSM were diagnosed with early syphilis. 110 (53%) were HIV-negative at baseline, 96 (47%) were HIV-positive. Only age (37 vs 32 years, p=0.0005) was significantly different according to HIV status of MSM at baseline. In HIV-negative versus HIV-positive MSM, incidence of rectal chlamydia infection at follow-up was 27 cases vs 50/100 person-years of follow-up (PYFU) (p=0.0039), 33 vs 66/100 PYFU (p=0.0044) for rectal gonorrhoea and 10 vs 26/100 PYFU (p=0.0044) for syphilis reinfection, respectively. Total follow-up for 110 HIV-negative MSM was 144 person-years. HIV incidence was 8.3/100 PYFU (CI 4.2 to 14). Conclusions A diagnosis of early syphilis carries a high risk of consequent HIV seroconversion and should warrant prioritised access to prevention measures such as PrEP and regular STI screening to prevent HIV transmission.

Outcomes of acutely HIV-1-infected individuals following rapid antiretroviral therapy initiation.

BACKGROUND Few data exist on the benefits and acceptability of rapid initiation of antiretroviral treatment in acute HIV infection (AHI). We analysed a large cohort of acutely infected HIV patients starting antiretroviral therapy (ART) to determine uptake, linkage into care and time to achieve viral suppression. METHODS Case notes of all individuals diagnosed with AHI between May 2014 and October 2015 at 56 Dean Street, a sexual health clinic in London, UK were reviewed. AHI was defined through documentation of plasma HIV RNA positivity only, plasma HIV RNA and p24 antigen positivity with a negative HIV enzyme immunoassay (EIA) test or HIV EIA test switching from negative to positive within 6 weeks. Between-group comparisons of time to viral suppression according to ART chosen were performed using the log-rank test. RESULTS We identified 113 individuals with AHI. Linkage to care was 95%. 77% of patients started ART at first medical appointment: all men who have sex with men, median age 35 years, median viral load (VL) log10 6.45, median CD4+ T-cell count 483 cells/mm3. Median time from diagnosis to ART initiation was 20 days. At 24 weeks, no patients had discontinued ART; 99% of patients achieved viral suppression by 24 weeks, with a median time to documented VL suppression of 74 days. Viral suppression was more rapid with integrase inhibitors compared with other regimens (median 41 versus 88.5 days, P<0.05). CONCLUSIONS In acute HIV infection, individuals demonstrated high ART uptake and rapid VL suppression suggesting that early treatment with antiretrovirals is acceptable and efficacious.

O19 Can express treatment reduce onward transmission

Background/introduction The introduction of onsite Cepheid® GeneXpert diagnostics for asymptomatic STI screens cut ‘test to treatment’ time by 190 h. Aim(s)/objectives To evaluate the Public Health benefit of faster treatment. Methods Patients with chlamydia (CT) and/or gonorrhoea (GC) over 8 weeks in February 2014 were retrospectively identified. We compared the timing of testing, treatment and number of recent sexual partners with a control group from November 2013. Assuming rate of partners remains unchanged, we calculated ‘partners spared’ exposure per infected patient due to faster treatment. Results 431 patients were identified with CT and/or GC infection. 81% (349/431) were MSM. Median age was 29 years. 23% of index patients disclosed high risk behaviour including fisting, chemsex and injecting drug use. Median ‘test to treatment’ time dropped from 238 h to 48 h. The number of partners spared exposure was 0.5 per index case. This equates to a total 196 partners spared exposure over the study period. Discussion/conclusion For every two people diagnosed with an infection, one partner was spared exposure. Limiting the duration of infectivity and the potential for onward transmission has clear public health benefits and is of particular value in this cohort with multiple partners who engage in high-risk behaviour.

InterPrEP: internet-based pre-exposure prophylaxis (PrEP) with generic tenofovir DF/emtricitabine (TDF/FTC) in London – analysis of pharmacokinetics, safety and outcomes

Scientific advances over the 35 years since AIDS was first recognized as a new disease, have put us on a clear path towards ending the HIV/AIDS pandemic. Scaling‐up access to antiretroviral therapy (ART) and HIV prevention strategies, such as pre‐exposure prophylaxis, could dramatically decrease HIV‐related deaths and the rate of new HIV infections. Current and future scientific advances, notably in HIV vaccine and cure research, will accelerate this process. Two major directions in HIV vaccine development will be discussed: building on the results from RV 144, the clinical trial in Thailand that resulted in the first modest signal of efficacy for a HIV vaccine; and structure‐based immunogen design to elicit broadly neutralizing antibodies. Cure research has accelerated greatly over the past few years in two areas. The first is the prospect of eradicating the HIV reservoir altogether (i.e. a classic cure), which might involve novel latency‐reversing and immunotoxic regimens and gene editing techniques to create a host cellular environment that does not allow HIV replication. The second approach involves controlling viral rebound following discontinuation of ART to achieve sustained virological remission employing strategies, such as passive transfer of broadly neutralizing antibodies and therapeutic vaccination. In 2016, the arsenal of scientifically proven interventions available, as well as the hope of others to come, offer unprecedented opportunities to make major gains in the fight against HIV/AIDS. With a major global commitment to implement these scientific advances, the end of the HIV/AIDS pandemic is now achievable.

Is PEP prescribed appropriately

We describe the characteristics of HIV post‐exposure prophylaxis (PEP) recipients and PEP indications at 56 Dean Street, a central London sexual health clinic. PEP was prescribed on 577 occasions. Most (97%) was given for unprotected anal intercourse. Over a fifth of exposures involved recreational drug use. Of the patients prescribed PEP, 5.9% were given PEP more than once in this period. As a snapshot of HIV risk behaviour, we note the prevalence of drug use, sex without condom use and group sex among PEP recipients.

InterPrEP: internet‐based pre‐exposure prophylaxis with generic tenofovir disoproxil fumarate/emtrictabine in London – analysis of pharmacokinetics, safety and outcomes

The National Health Service in England (NHS England) does not provide pre‐exposure prophylaxis (PrEP) against HIV, forcing people to purchase generic versions on the internet. However, there are concerns about the authenticity of medicines purchased online. We established an innovative service offering plasma tenofovir (TFV) and emcitrabine (FTC) therapeutic drug monitoring for people buying generic PrEP online, to ensure that drug concentrations in vivo were consistent with those of propriety brands and previously published data.

Evolution of a pre-exposure prophylaxis (PrEP) service in a community-located sexual health clinic: concise report of the PrEPxpress

Screening and treatment of sexually transmissible infections, including HIV, are free in the UK nations; pre-exposure prophylaxis (PrEP) became free in England in October 2017 through the PrEP Impact trial. Doctor-led PrEP clinics started at 56 Dean Street in September 2015, with the drug purchased privately at full price. The service was expanded to other staff to support initiation and monitoring of increasing numbers of attendees purchasing PrEP from online pharmacies. Nonetheless, when the clinic was given a target of 1700 for the PrEP Impact trial, it was clear this could not be achieved in a timely manner through 56 Dean Street alone. To prepare for the trial, all staff with HIV testing competencies were trained in good clinical practice and trial-specific procedures, and a patient group directive was approved to facilitate nurse prescribing and dispensing. Electronic pro formas to capture eligibility for starting or continuing PrEP were adapted for the Dean Street Express clinic, with some information collected directly from service users using touch screens. These interventions, together with an update to the 2016 information leaflet developed by the community, enabled enrolment and follow-up of 1700 participants in 4 months. PrEP advice and monitoring were easily accommodated in the 56 Dean Street sexual health service, but did require additional training and approval for nurse prescribing and dispensing drug in order to achieve the target, which still fell short of the demand.

Rapid testing and treatment for sexually transmitted infections improve patient care and yield public health benefits

A service evaluation of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) testing and result notification in patients attending a rapid testing service (Dean Street Express [DSE]) compared with those attending an existing ‘standard’ sexual health clinic (56 Dean Street [56DS]), and modelling the impact of the new service from 1 June 2014 to 31 May 2015. Primary outcome: time from patients’ sample collection to notification of test results at DSE compared with 56DS. Secondary outcomes estimated using a model: number of transmissions prevented and the number of new partner visits avoided and associated cost savings achieved due to rapid testing at DSE. In 2014/15, there were a total of 81,352 visits for CT/NG testing across 56DS (21,086) and DSE (60,266). Rapid testing resulted in a reduced mean time to notification of 8.68 days: 8.95 days for 56DS (95% CI 8.91–8.99) compared to 0.27 days for DSE (95% CI 0.26–0.28). Our model estimates that rapid testing at DSE would lead to 196 CT and/or NG transmissions prevented (2.5–97.5% centile range = 6–956) and lead to annual savings attributable to reduced numbers of partner attendances of £124,283 (2.5–97.5% centile range = £4260–590,331). DSE, a rapid testing service for asymptomatic infections, delivers faster time to result notification for CT and/or NG which enables faster treatment, reduces infectious periods and leads to fewer transmissions, partner attendances and clinic costs.